Use of Low-Molecular-Weight Heparins in the Management of Acute Coronary Artery Syndromes and Percutaneous Coronary Intervention

Wong, Graham C.; Giugliano, Robert P.; Antman, Elliott M.

doi:10.1001/jama.289.3.331

Cited by 84 publications

(37 citation statements)

References 85 publications

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“…132 Routine assays for LMWH monitoring (antifactor Xa levels) are not widely available, but the data suggest that monitoring may be helpful in high-risk patient groups including pregnant women, patients at weight extremes, and people with chronic renal impairment. [131][132][133] The efficacy and safety of enoxaparin in patients with UA/NSTEMI undergoing an invasive strategy has been studied in 2 noninferiority trials: the A-to-Z (Aggrastat to Zocor phases) 134 (nϭ3987 patients; 29% women) and SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) 135 (nϭ9978 patients; 34% women) studies. No statistically significant benefit was noted for enoxaparin over standard UFH in the setting of PCI for ACS in either women or men, and evidence was found for a slight increase in bleeding complications with enoxaparin.…”

Section: Low-molecular-weight Heparinmentioning

confidence: 99%

Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women

Lansky¹,

Hochman²,

Ward³

et al. 2005

Circulation

214

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Abstract-More than 1.2 million percutaneous coronary interventions are performed annually in the United States, with only an estimated 33% performed in women, despite the established benefits of percutaneous coronary intervention and adjunctive pharmacotherapy in reducing fatal and nonfatal ischemic complications in acute myocardial infarction and high-risk acute coronary syndromes. This statement reviews sex-specific data on the safety and efficacy of contemporary interventional therapies in women. 1 Despite the fact that more women than men die from cardiovascular disease in the United States, and despite the established benefits of PCI in reducing fatal and nonfatal ischemic complications in patients with acute myocardial infarction and high-risk acute coronary syndromes, only an estimated 33% of annual PCIs are performed in women. [1][2][3][4] In addition, women experience greater delays 5 to intervention and are referred for diagnostic catheterization less frequently than are men. 6 -8 Although suggested reasons for referral differences have included women's older age at presentation, greater risk profile, and increased risk for an adverse procedural outcome, as well as differences in symptoms and pain perception between men and women and lower predictive accuracy of noninvasive testing in women, some evidence suggests a potential sex and race bias. 9 In contrast, once women are referred for cardiac catheterization, revascularization rates and practices are similar to those in men. 10 -12 Recent advances in angioplasty equipment and technique have improved options for patients with smaller coronary and peripheral (access) arteries. In addition, the increased use of stents and adjunctive pharmacotherapy has improved outcomes in both women and men. Nevertheless, women continue to represent 15% to 38% of the population in studies of PCI, and still relatively few sex-or race-specific data exist.The purpose of this statement is to review what is known and not known about PCI in women and to put published data in context with contemporary coronary intervention. It is not the intention of the writing group to give specific treatment recommendations but rather to compile and collate the available sex-specific data on the safety and efficacy of interventional therapies in women. Tables 1 and 3 provide summaries of the findings in women drawn from this literature review, as well as recommendations from previously published American College of Cardiology/American Heart Association (ACC/AHA) guidelines. MethodsThe information in this statement was compiled by systematic literature review. By searching MEDLINE from JanuaryThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perc...

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Section: Low-molecular-weight Heparinmentioning

confidence: 99%

Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women

Lansky¹,

Hochman²,

Ward³

et al. 2005

Circulation

214

View full text Add to dashboard Cite

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“…Inclusion criteria were ischemic symptoms at rest lasting at least 10 min within 24 h before randomization and either ‡ 1.0 mm of ST-segment depression in two contiguous electrocardiogram leads, ‡ 1. , platelet count < 120 mm 3 , creatinine > 1.8 mg dL , greater than normal prothrombin time); or an uninterpretable ST-segment on their baseline electrocardiogram. An amendment to the protocol after approximately 200 patients were enrolled permitted the inclusion of patients who had received heparin or LMWH for < 72 h.…”

Section: Patientsmentioning

confidence: 99%

“…2 Designed, monitored, and provided oversite of the trial and planned and interpreted the trial analyses. 3 Performed the statistical analyses and assisted in interpretation of the results. 4 Performed critical review of multiple drafts of the manuscript.…”

Section: Contribution Of Authorsmentioning

confidence: 99%

First experience with direct, selective factor Xa inhibition in patients with non-ST-elevation acute coronary syndromes: results of the XaNADU-ACS Trial

Alexander

Yang

Becker

et al. 2005

Journal of Thrombosis and Haemostasis

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See also Rajagopal V, Bhatt DL. Factor Xa inhibitors in acute coronary syndromes: moving from mythology to reality. This issue, pp 436-8.Summary. Background: Unfractionated heparin is widely used in patients with non-ST-elevation acute coronary syndromes but has important limitations. Anticoagulants with predictable kinetics and anticoagulant effects, better efficacy, and greater safety are needed. Objective: To investigate the efficacy and safety of a direct, selective factor Xa inhibitor, DX-9065a (Daiichi Pharmaceuticals LTD, Inc.) compared with heparin, in patients with non-ST-elevation acute coronary syndromes. Patients and methods: Patients (n ¼ 402) from the USA, Canada, and Japan were randomized to blinded, weight-adjusted heparin, low-dose DX-9065a, or high-dose DX-9065a. Results The primary efficacy endpoint of death, myocardial infarction, urgent revascularization, or ischemia on continuous ST-segment monitoring occurred in 33.6%, 34.3%, and 31.3% of patients assigned to heparin, low-dose DX-9065a, and high-dose DX-9065a (P ¼ 0.91 for heparin vs. combined DX-9065a). The composite of death, myocardial infarction, or urgent revascularization occurred in 19.5%, 19.3%, and 11.9% (P ¼ 0.125 for heparin vs. high-dose DX-9065a) of patients; major or minor bleeding occurred in 7.7%, 4.2%, and 7.0% of patients; and major bleeding in 3.3%, 0.8%, and 0.9% of patients. Higher concentrations of DX-9065a were associated with a lower likelihood of ischemic events (P ¼ 0.03) and a non-significant tendency toward a higher likelihood of major bleeding (P ¼ 0.32). Conclusions: In this small phase II trial, there was a non-significant tendency toward a reduction in ischemic events and bleeding with DX-9065a compared with heparin in patients with acute coronary syndromes. The absence of an effect on ST-monitor ischemia warrants further investigation. These data provide the rationale for adequately powered studies of DX-9065a in acute coronary syndromes or percutaneous intervention.

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“…Nonetheless, there are many disadvantages of UFH. 38 These include its nonspecific binding to and resulting inactivation by platelets, vascular endothelium, fibrin, platelet factor 4, and a variety of circulating proteins. The production of antiheparin antibodies may be associated with heparin-induced thrombocytopenia.…”

Section: Anticoagulant Therapy Ufhmentioning

confidence: 99%

“…These concerns are being allayed by a number of observational studies and registries using enoxaparin. 38,42 Importantly, enoxaparin was compared with UFH in 746 patients with UA/NSTEMI receiving aspirin and eptifibatide in the Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial. 43 The primary endpoint, non-CABG-associated major bleeding, was significantly lower in the enoxaparin compared to the UFH groups (1.8% versus 4.6%), although the relative incidence of minor bleeding was reversed.…”

Section: Lmwhmentioning

confidence: 99%

Application of Current Guidelines to the Management of Unstable Angina and Non-ST-Elevation Myocardial Infarction

Braunwald

2003

Circulation

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Abstract-Unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) is a common but heterogeneous disorder with patients exhibiting widely varying risks. Early risk stratification is at the center of the management program and can be achieved using clinical criteria and biomarkers, or a combination. In addition to anti-ischemic therapy and aspirin, the thienopyridine clopidogrel is indicated except in patients who are potential candidates for urgent coronary artery bypass grafting (CABG

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Use of Low-Molecular-Weight Heparins in the Management of Acute Coronary Artery Syndromes and Percutaneous Coronary Intervention

Cited by 84 publications

References 85 publications

Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women

Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women

First experience with direct, selective factor Xa inhibition in patients with non-ST-elevation acute coronary syndromes: results of the XaNADU-ACS Trial

Application of Current Guidelines to the Management of Unstable Angina and Non-ST-Elevation Myocardial Infarction

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