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European Heart Journal Advance Access published online on April 24, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm081
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: results from ExTRACT-TIMI 25

Harvey D. White1,*, Eugene Braunwald2, Sabina A. Murphy2, Ashok J. Jacob3, Nina Gotcheva4, Leonid Polonetsky5 and Elliott M. Antman2

1 Green Lane Cardiovascular Service, Auckland City Hospital, Auckland 1030, New Zealand
2 TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
3 St. John's Hospital, Livingston, West Lothian, UK
4 Cardiology Department, National Heart Center, Sofia, Bulgaria
5 Republic Research-Practical Center ‘Cardiology’, Minsk, Belarus

Received 18 December 2006; revised 22 February 2007; accepted 8 March 2007.

* Corresponding author. Tel: +64 9 630 9992; fax: +64 9 630 9915. E-mail address: harveyw{at}adhb.govt.nz

Aims: To determine the effects of age on outcomes in patients with STEMI treated with a strategy of enoxaparin (ENOX) vs. unfractionated heparin (UFH).

Methods and results: In the ExTRACT-TIMI 25 trial, 20 479 patients with STEMI were randomized in a double-blind fashion to UFH or ENOX. A novel reduced dose of ENOX was administered to patients ≥75 years, and a reduced dose in those with an estimated creatinine clearance of < 30 mL/min. Anti-Xa levels were measured in a subset of patients (n = 73). The exposure to anti-Xa over time was lower in the elderly (AUC0–12 h P < 0.0001; AUCsteady-state P = 0.0046). The relative risk reduction (RR) with ENOX on the primary endpoint, i.e. death or non-fatal recurrent myocardial infarction, was greater in patients < 75 years (20%) than > 75 years (6%), but the absolute benefits were similar. When compared with UFH, ENOX was associated with an RR of 1.67 for major bleeding, but the magnitude of the excess risk tended to be lower (RR = 1.15) in patients ≥ 75 years assigned to ENOX.

Conclusion: A dose reduction of ENOX in the elderly appears to be helpful in ameliorating bleeding risk. A strategy of ENOX was superior to UFH in both young and elderly patients with STEMI treated with fibrinolysis.

Key Words: ExTRACT-TIMI 25 • Enoxaparin • Unfractionated heparin • Age


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