Enoxaparin is superior to unfractionated heparin in patients with ST elevation myocardial infarction undergoing fibrinolysis regardless of the choice of lytic: an ExTRACT-TIMI 25 analysis

Giraldez, Roberto R.; Nicolau, José Carlos; Corbalán, Ramón; Gurfinkel, Enrique P.; Juárez, Úrsulo; López‐Sendón, José; Parkhomenko, Alexander; Molhoek, Peter; Mohanavelu, Satishkumar; Morrow, David A.; Antman, Elliott M.

doi:10.1093/eurheartj/ehm179

Cited by 59 publications

(22 citation statements)

References 17 publications

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“…No adequately powered trials have been conducted in PE patients comparing bleeding differences with fibrinspecific versus nonspecific agents. However, in myocardial infarction patients, major bleeding was lower with fibrin-specific lytics than with streptokinase [Giraldez et al 2007;GUSTO Investigators, 1993]. Thus increased fibrin-specificity remains a potential means to reduce bleeding without affecting efficacy.…”

Section: Thrombolytic Agentsmentioning

confidence: 99%

Bleeding risk with systemic thrombolytic therapy for pulmonary embolism: scope of the problem

Daley

Murthy

Peterson

2015

Therapeutic Advances in Drug Safety

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Acute pulmonary embolism represents a major complication of venous thromboembolism that is associated with high morbidity and mortality. Guidelines recommend the rapid initiation of anticoagulation and consideration of thrombolytic therapy in select patients, including those with hypotension or at high risk of developing hypotension. Evaluation for thrombolytic therapy should only be considered after assessment of contraindications and risk for major bleeding. The objective of this perspective article is to evaluate the bleeding risk associated with systemic thrombolytic therapy in the management of acute pulmonary embolism and discuss strategies to minimize this risk. Risk stratification of acute pulmonary embolism will be discussed to identify patient populations that warrant specific consideration of risk for major bleeding with thrombolytic therapy. In addition, the incidence, patient-specific risk factors, and pharmacologic characteristics, including concurrent anticoagulation and thrombolytic therapy, will be evaluated in the context of risk for major hemorrhage. Finally, supporting evidence for strategies to minimize risk of hemorrhage, including evaluation of contraindications, weight adjusted dosing, infusion strategy and catheter-directed thrombolytic administration will be evaluated. Despite published guidelines and review articles, select aspects to thrombolytic therapy for the management of pulmonary embolism remain controversial and under recognized, including risk of major hemorrhage. When making decisions about the role of thrombolytic therapy in pulmonary embolism, clinicians must be knowledgeable about the associated risks of thrombolytic therapy and individually evaluate patient risk factors prior to determining appropriate candidacy for thrombolytic therapy. For patients considered to be at high risk of major bleeding, strategies to minimize risk should be considered, including weight-adjusted doses and catheter directed therapy. Additional research is needed specific to the acute pulmonary embolism setting to validate risk factors and strategies to minimize major hemorrhage.

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Section: Thrombolytic Agentsmentioning

confidence: 99%

Bleeding risk with systemic thrombolytic therapy for pulmonary embolism: scope of the problem

Daley

Murthy

Peterson

2015

Therapeutic Advances in Drug Safety

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“…For patients with STEMI to be treated with fibrinolysis, 17 studies supported enoxaparin over UFH (LOE1 336,[387][388][389][390][391][392][393] ; LOE 2 341,394,395,396 ; LOE 4 397 ; LOE 5 393,396,398 -401 ) Twelve other studies were neutral comparing enoxaparin and UFH. [402][403][404][405][406][407][408][409][410][411] Reviparin.…”

Section: Consensus On Sciencementioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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“…El beneficio clínico neto observado (ausencia de muerte, infarto no mortal o hemorragia intracraneal) respalda el uso de enoxaparina. Dicho beneficio se observó con independencia del tratamiento fibrinolítico administrado y de la edad de los pacientes 88,89 . En el estudio OASIS-6, una dosis baja de fondaparinux, un inhibidor sintético indirecto del factor Xa, fue superior al placebo y la heparina en la prevención de muerte y reinfarto en 5.436 pacientes que recibieron tratamiento fibrinolítico 57 .…”

Section: Prevención Y Tratamiento De La Obstrucción Microvascular unclassified

ESC Guidelines on Management of Acute Myocardial Infarction in Patients Presenting With Persistent ST-Segment Elevation

Werf¹,

Bax²,

Betriu³

et al. 2009

Revista Española de Cardiología (English Edition)

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Enoxaparin is superior to unfractionated heparin in patients with ST elevation myocardial infarction undergoing fibrinolysis regardless of the choice of lytic: an ExTRACT-TIMI 25 analysis

Abstract: The benefits of an enoxaparin strategy over UFH were observed in both SK and fibrin-specific-treated STEMI patients. Therefore, an enoxaparin strategy is preferred over UFH to support fibrinolysis for STEMI regardless of lytic agent.

Cited by 59 publications

References 17 publications

Bleeding risk with systemic thrombolytic therapy for pulmonary embolism: scope of the problem

Bleeding risk with systemic thrombolytic therapy for pulmonary embolism: scope of the problem

Part 9: Acute Coronary Syndromes

ESC Guidelines on Management of Acute Myocardial Infarction in Patients Presenting With Persistent ST-Segment Elevation

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