Current and Future Options for Anticoagulant Therapy in the Acute Management of ACS
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Anticoagulation with a parenteral (intravenous or subcutaneous) antithrombin agent is foundational to the early management of acute coronary syndrome (ACS). While indications for, the timing of, and the choice among agents (other than aspirin) that provide antiplatelet effects are all subject to discussion, the need for acute anticoagulation is beyond question. There are a number of agents that can be used for anticoagulation in ACS, depending upon the intended near-term management of the patient (medical vs interventional), the patient’s ischemic risk, and the patient’s hemorrhagic risk. It is usually appropriate for therapy to be initiated in the emergency department (ED), which in turn supports close collaboration between “upstream” providers and interventional cardiologists. Clinical trial data suggest that “switching” agents during ACS care affords no efficacy advantage and may increase bleeding risk. At least 1 potential new agent (otamixaban) that can be used in all ACS care settings is on the near-term horizon, with the drug currently in late Phase III testing.
KeywordsAnticoagulation Acute coronary syndrome Heparin Fondaparinux Enoxaparin Bivalirudin Otamixaban Antithrombin
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as:• Of importance•• Of major importance
- 1.••Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update). Circulation. 2012;126:875–910. This is the most recent update of the American guidelines for NSTE-ACS management and serves as a useful reference, although there is scant mention of anticoagulation therapy therein.PubMedCrossRefGoogle Scholar
- 2.Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). Circulation. 2007;116:e148–304.PubMedCrossRefGoogle Scholar
- 3.Hamm CW, Bassand JP, Agewall S, et al. ESC Committee for Practice Guidelines Document Reviewers ESC Committee for Practice Guidelines. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2999–3054.PubMedCrossRefGoogle Scholar
- 9.Cohen M, Adams PC, Hawkins L, Bach M, Fuster V. Usefulness of antithrombotic therapy in resting angina pectoris or non- Q-wave myocardial infarction in preventing death and myocardial infarction (a pilot study from the antithrombotic therapy in acute coronary syndromes study group). Am J Cardiol. 1990;66:1287–92.PubMedCrossRefGoogle Scholar
- 10.Kushner FG, Hand M, Smith Jr SC, King III SB, Anderson JL, Antman EM, et al. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:2271–306.PubMedCrossRefGoogle Scholar
- 11.Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA 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 (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004; Available at www.acc.org/clinical/guidelines/stemi/index.pdf.
- 13.•Montalescot G, Zeymer U, Silvain J, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomized open-label ATOLL trial. Lancet. 2011;378(9792):693–703. Though underpowered, ATOLL suggested that enoxaparin might be as effective as UFH in the interventional management of STEMI, as well.PubMedCrossRefGoogle Scholar
- 15.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. JAMA. 2004;292:45–54.PubMedCrossRefGoogle Scholar
- 22.APPRAISE Steering Committee and Investigators, Alexander JH, Becker RC, et al. Apixaban, an oral, direct, selective factor Xa inhibitor, in combination with antiplatelet therapy after acute coronary syndrome: results of the Apixaban for Prevention of Acute Ischemic and Safety Events (APPRAISE) trial. Circulation. 2009;119:2877–85.PubMedCrossRefGoogle Scholar
- 30.••Sabatine MS, Antman EM, Widimsky P, et al. Otamixaban for the treatment of patients with non-ST-elevation acute coronary syndromes (SEPIA-ACS1 TIMI 42): a randomized, double-blind, active-controlled, phase 2 trial. Lancet. 2009;374:787–95. The study is the basis of the ongoing TAO trial and suggests that otamixaban may prove to be a superior agent for anticoagulation of ACS patients across the continuum of care.PubMedCrossRefGoogle Scholar