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European Heart Journal Advance Access originally published online on October 26, 2007
European Heart Journal 2007 28(23):2952; doi:10.1093/eurheartj/ehm470
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Enoxaparin and ST elevation myocardial infarction

Andrew Owen

Department of Cardiology
Kent and Canterbury Hospital
Ethelbert Road Canterbury Kent CT1 3NG
UK

Tel/fax: +44 1227 766877

The ExTRACT-TIMI 25 investigators conclude that enoxaparin is superior to intravenous unfractionated heparin in patients with ST elevation myocardial infarction undergoing fibrinolysis, with either a fibrin-specific agent or streptokinase.1 Since intravenous unfractionated heparin has not been demonstrated to be superior to placebo in this context,2 the relevance of this finding to clinical practice is not clear. The investigators cite a review3 as evidence that unfractionated heparin is efficacious for patients with ST elevation myocardial infarction treated with fibrinolysis and aspirin. In fact, this review3 concludes with the statement ‘Nor is there good evidence that, among patients who are given aspirin and fibrinolytic therapy, the routine addition of either intravenous or subcutaneous heparin produces any worthwhile improvement in outcome’.

The pertinent clinical question is: does the addition of enoxaparin to standard therapy (fibrinolysis plus aspirin) for ST elevation myocardial infarction improve outcome? Unfortunately, this question remains unanswered. We cannot assume that intravenous unfractionated heparin is a surrogate for placebo. The small number of studies that have compared unfractionated heparin with placebo have been underpowered to detect any likely benefit either individually or as part of a meta-analysis.2 Therefore, whether unfractionated heparin is slightly better or worse than placebo remains unknown. The finding that enoxaparin is marginally superior to unfractionated heparin does not allow us to conclude that it is superior to placebo.

References

  1. Giraldez RR, Nicolau JC, Corbalan R, Gurfinkel EP, Juarez U, Lopez-Sendon J, Parkhomenko A, Molhoek P, Mohanavelu S, Morrow DA, Antman EM. 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. Eur Heart J (2007) 28:1566–1573.[Abstract/Free Full Text]
  2. Eikelboom JW, Quinlan DJ, Mehta SR, Turpie AG, Menown IB, Yusuf S. 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.[Abstract/Free Full Text]
  3. Collins R, Peto R, Baigent C, Sleight P. Aspirin, heparin and fibrinolytic therapy in suspected acute myocardial infarction. N Eng J Med (1997) 336:847–860.[Free Full Text]

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This Article
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28/23/2952    most recent
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