European Heart Journal Advance Access originally published online on October 26, 2007
European Heart Journal 2007 28(23):2952-2953; doi:10.1093/eurheartj/ehm471
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Enoxaparin and ST-elevation myocardial infarction: reply
TIMI Study GroupCardiovascular DivisionDepartment of Medicine
Brigham and Women's HospitalHarvard Medical School 350 Longwood Avenue, 1st Floor Boston, MA 02115,
USA
TIMI Study GroupCardiovascular DivisionDepartment of Medicine
Brigham and Women's HospitalHarvard Medical School 350 Longwood Avenue, 1st Floor Boston, MA 02115,
USA
E-mail address: rgiraldez{at}partners.or
The current versions of the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines recommend the use of unfractionated heparin (UFH) with fibrin-specific lytics (Class I) or streptokinase (Class II).1,2 The indication for the combined use of an antithrombin with fibrinolytic therapy is based on the desire to treat the increase in procoagulant activity secondary to thrombin generation associated with lytic administration, higher early patency rates in ST-elevation myocardial infarction (STEMI) patients treated with UFH compared with placebo in angiographic studies, and reduced rates of death and myocardial infarction in a large meta-analysis comparing UFH to placebo with fibrinolysis. In this analysis, a significant reduction (P = 0.03) of five lives per 1000 patients is seen when UFH is used in conjunction with a non-fibrin-specific fibrinolytic in the presence of aspirin.3
Our analysis demonstrates a significant reduction of death and non-fatal myocardial infarction in patients receiving fibrinolytic therapy with enoxaparin when compared with UFH regardless of the lytic agent administered.4 In conjunction with the CREATE trial (reviparin vs. placebo) and the comparison of fondaparinux with placebo in stratum I of the OASIS-6 study (UFH not indicated), our ExTRACT-TIMI 25 analysis emphasizes the importance of adding antithrombin therapy across the spectrum of fibrinolytic therapy currently in use, including streptokinase.5,6 These findings led to the FDA-approved change in the package insert for enoxaparin to include the use of this antithrombin agent in STEMI patients undergoing fibrinolysis.
References
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[Free Full Text] - Collins R, Peto R, Baigent C, Sleight P. Aspirin, heparin, and fibrinolytic therapy in suspected acute myocardial infarction. N Engl J Med (1997) 336:847–860.
[Free Full Text] - 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] - Yusuf S, Mehta SR, Xie C, Ahmed RJ, Xavier D, Pais P, Zhu J, Liu L. Effects of reviparin, a low-molecular-weight heparin, on mortality, reinfarction, and strokes in patients with acute myocardial infarction presenting with ST-segment elevation. JAMA (2005) 293:427–435. CREATE Trial Group Investigators.
[Abstract/Free Full Text] - Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, Granger CB, Budaj A, Peters RJ, Bassand JP, Wallentin L, Joyner C, Fox KA. 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. OASIS-6 Trial Group.[CrossRef][Web of Science][Medline]
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