Which heparin and how much?
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Acute coronary syndromes (ACS) are among the most common presentations to emergency departments in North America. An important therapeutic decision facing the clinician is whether antithrombotic therapy is justified and which type confers the lowest risk:benefit ratio. Using low molecular weight heparin (LMWH) has resulted in improved cardiovascular outcomes over unfractionated heparin in the noninvasively treated; however, its use as the antithrombotic agent in the invasive management of ACS has not always been superior. There have also been concerns about bleeding risk with LMWH, especially in the elderly and those with impaired renal function. The longer half-life of LMWH and the complexity of reversing its effect, in the context of multiple antiplatelet and fibrinolytic drugs, have also spurred debate. Finally, there is concern over unwanted thrombotic events with these agents in the cardiac catheterization laboratory.
- MIMS Point of Care database, CMP Medica Australia 2007: Heparin sodium injection. http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=311&product_name=Heparin+Sodium+Injection. Enoxaparinsodium. http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2658&product_name=Clexane+and+Clexane+Forte. http://www.mims.com.au.. Accessed February 2008.
- Hirsh J, Fuster V: Guide to anticoagulant therapy. Part 1: heparin. American Heart Association. Circulation 1994, 89:1449–1468.
- Rich JD, Maraganore JM, Young E, et al.: Heparin resistance in acute coronary syndromes. J Thromb Thrombolysis 2007, 23:93–100. CrossRef
- Xiao Z, Theroux P: Platelet activation with unfractionated heparin at therapeutic concentrations and comparisons with a low-molecular-weight heparin and with a direct thrombin inhibitor. Circulation 1998, 97:251–256.
- University of Washington Medical Center Anticoagulation Services: Guidelines for dosing and monitoring enoxaparin. http://www.uwmcacc.org/Enoxaparin.html. Accessed February 2008.
- Telford AM, Wilson C: Trial of heparin versus atenolol in prevention of myocardial infarction in intermediate coronary syndrome. Lancet 1981, 1:1225–1228. CrossRef
- Théroux P, Ouimet H, McCans J, et al.: Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med 1988, 319:1105–1111.
- Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. The RISC Group [no authors listed]. Lancet 1990, 336:827–830.
- NeriSerneri GG, Modesti PA, Gensini GF, et al.: Randomised comparison of subcutaneous heparin, intravenous heparin, and aspirin in unstable angina. Studio Epoorine Sottocutanea nell’Angina Instobile (SESAIR) Refrattorie Group. Lancet 1995, 345:1201–1204. (Published erratum appears in Lancet 1995, 346:130.) CrossRef
- Théroux P, Waters D, Qiu S, et al.: Aspirin versus heparin to prevent myocardial infarction during the acute phase of unstable angina. Circulation 1993, 88(5 Pt 1):2045–2048.
- Braunwald E, Antman EM, Beasley JW, et al.: ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Available at http://www.acc.org/qualityandscience/clinical/guidelines/unstable/update_index.htm. Accessed February 2008.
- Melloni C, Alexander KP, Chen AY, et al.: Unfractionated heparin dosing and major bleeding in non-ST-segment elevation acute coronary syndromes [abstract 1800]. Circulation 2007, 116:II383.
- Théroux P, Waters D, Lam J, et al.: Reactivation of unstable angina after the discontinuation of heparin. N Engl J Med 1992, 327:141–145.
- Bijsterveld NR, Peters RJ, Murphy SA, et al.: Recurrent cardiac ischemic events early after discontinuation of short-term heparin treatment in acute coronary syndromes: results from the Thrombolysis in Myocardial Infarction (TIMI) 11B and Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) studies. J Am Coll Cardiol 2003, 42:2083–2089. CrossRef
- Antman EM, McCabe CH, Gurfinkel EP, et al.: Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation 1999, 100:1593–1601.
- Bijsterveld NR, Moons AH, Meijers JC, et al.: Rebound thrombin generation after heparin therapy in unstable angina. A randomized comparison between unfractionated and low-molecular-weight heparin. J Am Coll Cardiol 2002, 39:811–817. CrossRef
- Dose-ranging trial of enoxaparin for unstable angina: results of TIMI 11A. The Thrombolysis in Myocardial Infarction (TIMI) 11A Trial Investigators [no authors listed]. J Am Coll Cardiol 1997, 29:1474–1482.
- Goodman SG, Cohen M, Bigonzi F, et al.: Randomized trial of low molecular weight heparin (enoxaparin) versus unfractionated heparin for unstable coronary artery disease: one-year results of the ESSENCE Study. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events. J Am Coll Cardiol 2000, 36:693–698. CrossRef
- Mark DB, Cowper PA, Berkowitz SD, et al.: Economic assessment of low-molecular-weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events [unstable angina or non-Q-wave myocardial infarction]. Circulation 1998, 97:1702–1707.
- Blazing MA, de Lemos JA, White HD, et al.: Safety and efficacy of enoxaparin vs unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes who receive tirofiban and aspirin: a randomized controlled trial. A to Z Investigators. JAMA 2004, 292:55–64. (Published erratum appears in JAMA 2004, 292:1178.) CrossRef
- Ferguson JJ, Califf RM, Antman EM, et al.: Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. SYNERGY Trial Investigators. JAMA 2004, 292:45–54. CrossRef
- Low-molecular-weight heparin during instability in coronary artery disease, Fragmin during Instability in Coronary Artery Disease (FRISC). FRISC study group [no authros listed]. Lancet 1996, 347:561–568.
- Klein W, Buchwald A, Hillis SE, et al.: Comparison of low-molecular-weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease. Fragmin in unstable coronary artery disease study (FRIC). Circulation 1997, 96:61–68. (Published erratum appears in Circulation 1998, 97:413.)
- Long-term low-molecular-mass heparin in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC). FRISC Investigators [no authors listed]. Lancet 1999, 354:701–707. (Published erratum appears in Lancet 1999, 354:1478.)
- Murphy SA, Gibson CM, Morrow DA, et al.: Efficacy and safety of the low-molecular weight heparin enoxaparin compared with unfractionated heparin across the acute coronary syndrome spectrum: a meta-analysis. Eur Heart J 2007, 28:2077–2086. CrossRef
- Yusuf S, Mehta SR, Chrolavicus S, et al.: Comparison of fondaparinux and enoxaparin in acute coronary syndromes. Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. N Engl J Med 2006, 354:1464–1476. CrossRef
- Mehta SR, Granger CB, Eikelboom JW, et al.: Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: results from the OASIS-5 trial. J Am Coll Cardiol 2007, 50:1742–1751. CrossRef
- Stone GW, McLaurin BT, Cox DA, et al.: Bivalirudin for patients with acute coronary syndromes. ACUITY Investigators. N Engl J Med 2006, 355:2203–2216. CrossRef
- Antman EM, Hand M, Armstrong PW, et al.: 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Canadian Cardiovascular Society; American Academy of Family Physicians; American College of Cardiology; American Heart Association. J Am Coll Cardiol 2008, 51:210–247. CrossRef
- Eikelboom JW, Quinlan DJ, Mehta SR, et al.: Unfractionated and low-molecular-weight heparin as adjuncts to thrombolysis in aspirin-treated patients with ST-elevation acute myocardial infarction: a meta-analysis of the randomized trials. Circulation 2005, 112:3855–3867. CrossRef
- Antman EM, Morrow DA, McCabe CH, et al.: Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. ExTRACT-TIMI 25 Investigators. N Engl J Med 2006, 354:1477–1488. CrossRef
- Nallamothu BK, Bates ER, Hochman JS, et al.: Prognostic implication of activated partial thromboplastin time after reteplase or half-dose reteplase plus abciximab: results from the GUSTO-V trial. Eur Heart J 2005, 26:1506–1512. CrossRef
- Sabatine MS, Morrow DA, Montalescot G, et al.: Angiographic and clinical outcomes in patients receiving low-molecular-weight heparin versus unfractionated heparin in ST-elevation myocardial infarction treated with fibrinolytics in the CLARITY-TIMI 28 Trial. Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 Investigators. Circulation 2005, 112:3846–3854. CrossRef
- Fox KA, Antman EM, Montalescot G, et al.: The impact of renal dysfunction on outcomes in the ExTRACT-TIMI 25 trial. J Am Coll Cardiol 2007, 49:2249–2255. CrossRef
- Keeley EC, Boura JA, Grines CL: Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet 2006, 367:579–588 (Published erratum appears in Lancet 2006, 367:1656.) CrossRef
- Popma JJ, Berger P, Ohman EM, et al.: Antithrombotic therapy during percutaneous coronary intervention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Ghest 2004, 126(3 Suppl):576S–599S.
- Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Lancet 2000, 356:2037–2044. (Published erratum appears in Lancet 2001, 357:1370.)
- Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. The EPILOG Investigators. N Engl J Med 1997, 336:1689–1696.
- Brener SJ, Moliterno DJ, Lincoff AM, et al.: Relationship between activated clotting time and ischemic or hemorhagic complications: analysis of 4 recent randomized clinical trials of percutaneous coronary intervention. Circulation 2004, 110:994–998. CrossRef
- Welsh RC, Gordon P, Westerhout CM, et al.: A novel enoxaparin regime for ST elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: a WEST sub-study. Catheter Cardiovasc Interv 2007, 70:341–348. CrossRef
- Medina HM, Cheong BYC, O’Meallie L, et al.: The safety and efficacy of enoxaparin as antithrombin therapy during primary percutaneous coronary intervention for ST-elevation myocardial infarction [abstract]. Cardiovasc Reveasc Med 2007, 8:116–154.
- Yusuf S, Mehta SR, Chrolavicius S, et al.: Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA 2006, 295:1519–1530. CrossRef
- Which heparin and how much?
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