Abstract
In addition to antiplatelet therapy with aspirin, anticoagulation therapy with unfractionated heparin decreases the risk of myocardial infarction and death in patients with acute coronary syndromes. However, unfractionated heparin has pharmacologic limitations that limit efficacy and safety. Enoxaparin, fondaparinux, and bivalirudin are new anticoagulant therapy options with either superior efficacy or better safety than unfractionated heparin. Compared with unfractionated heparin, enoxaparin and fondaparinux are easier to administer, do not require monitoring, and facilitate longer treatment duration. Bivalirudin offers advantages for patients undergoing early percutaneous revascularization. Careful attention to dosing and excellent vascular access site management after cardiac catheterization are required to decrease the risk of bleeding and blood transfusion, which have been associated with increased mortality risk.
Similar content being viewed by others
References and Recommended Reading
Of major importance Antman EM, Anbe DT, Armstrong PW, et al.:ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).Circulation 2004,110:e82-e292. ACC/AHA guidelines for STEMI.
Antman EM, Hand M, Armstrong PW, et al.:June 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association task force on practice guidelines.Circulation 2007, in press.
Van de Werf F, Ardissino D, Betriu A, et al.:Management of acute myocardial infarction in patients presenting with ST-segment elevation. The task force on the management of acute myocardial infarction of the European Society of Cardiology.Eur Heart J 2003,24:28–66.
Braunwald E, Antman EM, Beasley JW, et al.:ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the management of patients with unstable angina).Circulation 2002,106:1893–1900.
Bertrand ME, Simoons ML, Fox KA, et al.:Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J 2002,23:1809–1840.
Konkle BA, Schafer AI:Hemostasis, thrombosis, fibrinolysis, and cardiovascular disease. InBraunwald’s Heart Disease, vol 2, edn 7. Edited by Braunwald E, Zipes DP, Libby P, Bonow RO. Philadelphia: WB Saunders; 2005:2067–2092.
Bates ER:Bivalirudin: an anticoagulant option for percutaneous coronary intervention Expert Rev Cardiovasc Ther 2004:153–162.
Brummel KE, Paradis SG, Butenas S, Mann KG:Thrombin functions during tissue factor-induced blood coagulation.Blood 2002,100:148–152.
Hoffman M, Monroe DM:A cell-based model of hemostasis.Thromb Haemost 2001,85, 958–965.
Monroe DM, Hoffman M, Roberts HR:Platelets and thrombin generation.Arterioscler Thromb Vasc Biol 2002,22:1381–1389.
Coughlin SR:Thrombin signaling and protease-activated receptors.Nature 2000,407:258–264.
The GUSTO Investigators:An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.N Engl J Med 1993,329:673–682.
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.
Wong GC, Giugliano RP, Antman EM:Use of low-molecular-weight heparins in the management of acute coronary artery syndromes and percutaneous coronary intervention.JAMA 2003,289:331–342.
ASSENT-3 Investigators:Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction.Lancet 2001,358:605–613.
Wallentin L, Goldstein P, Armstrong PW, et al.:Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 plus randomized trial in acute myocardial infarction.Circulation 2003,108:135–142.
Of importance Antman EM, Morrow DA, McCabe CH, et al.:Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction.N Engl J Med 2006,354:1477–1488. This trial established enoxaparin as an anticoagulant option in patients with STEMI treated with fibrinolytic therapy.
Gibson CM, Murphy SA, Montalescot G, et al.:Percutaneous coronary intervention in patients receiving enoxaparin or unfractionated heparin following fibrinolytic therapy for ST-elevation myocardial infarction in the EXTRACT-TIMI 25 trial.J Am Coll Cardiol 2007, in press.
Of importance Yusuf S, Mehta SR, Chrolavicius S, et al.: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. This trial established fondaparinux as an anticoagulant option in patients with STEMI not undergoing early PCI.
White HD, Aylward PE, Frey MJ, et al.:Randomized, double-blind comparison of hirulog versus heparin in patients receiving streptokinase and aspirin for acute myocardial infarction (HERO). Hirulog Early Reperfusion/Occlusion (HERO) trial investigators.Circulation 1997,96:2155–2161.
White H:Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial.Lancet 2001,358:1855–1863.
Eikelboom JW, Anand SS, Malmberg K, et al.:Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis.Lancet 2000,355:1936–1942.
Cohen M, Demers C, Gurfinkel EP, et al.:A comparison of low-molecular weight heparin with unfractionated heparin for unstable coronary artery disease.N Engl J Med 1997,337:447–452.
Antman EA, McCabe CH, Gurfinkel EP, et al.:Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: results of the TIMI 11B trial.Circulation 1999,100:1593–1601.
Antman EM, Cohen M, Radley D, et al.:Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction. TIMI 11B-ESSENCE meta-analysis.Circulation 1999,100:1602–1608.
Cohen M, Theroux P, Borzak S, et al.:Randomized double-blind safety study of enoxaparin versus unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes treated with tirofiban and aspirin: the ACUTE II study.Am Heart J 2002,144:470–477.
Goodman SG, Fitchett D, Armstrong PW, et al.:Randomized evaluation of the safety and efficacy of enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes receiving the glycoprotein IIb/IIIa inhibitor eptifibatide.Circulation 2003,107:238–244.
Blazing MA, de Lemos JA, White HD, et al.:Safety and efficacy of enoxaparin vs unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes who receive tirofiban and aspirin: a randomized controlled trial.JAMA 2004,292:55–64.
Of importance The SYNERGY Trial Investigators:Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial.JAMA 2004,292:45–54. Most recent trial of enoxaparin in NSTE-ACS.
Petersen JL, Mahaffey KW, Hasselblad V, et al.:Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-segment elevation acute coronary syndromes. A systemic overview.JAMA 2004,292:89–96.
Of importance Yusuf S, Mehta SR, Chrolavicius S, et al.: for the OASIS-5 Investigators:Comparison of fondaparinux and enoxaparin in acute coronary syndromes.N Engl J Med 2006,354:1464–1476. This trial established fondaparinux as an anticoagulant option in patients with NSTE-ACS.
Antman EM, McCabe CH, Braunwald E:Bivalirudin as a replacement for unfractionated heparin in unstable angina/non-ST-elevation myocardial infarction: observations from the TIMI 8 trial.Am Heart J 2002,143:229–234.
Lincoff AM, Bittl JA, Harrington RA, et al.: for the REPLACE-2 Investigators:Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention. REPLACE-2 randomized trial.JAMA 2003:289:853–863.
Rajagopal V, Lincoff AM, Cohen DJ, et al.:Outcomes of patients with acute coronary syndromes who are treated with bivalirudin during percutaneous coronary intervention: an analysis from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) trial.Am Heart J 2006,152:149–154.
Gibson CM, Morrow DA, Murphy SA, et al.:A randomized trial to evaluate the relative protection against post-percutaneous coronary intervention microvascular dysfunction, ischemia, and inflammation among antiplatelet and antithrombotic agents: the PROTECT-TIMI 30 trial.J Am Coll Cardiol 2006,47:2364–2373.
Of importance Stone GW, McLaurin BT, Cox DA, et al.: for the ACUITY Investigators:Bivalirudin for patients with acute coronary syndromes.N Engl J Med 2006,355:2203–2216. This trial established bivalirudin as an anticoagulant option in patients with NSTE-ACS undergoing early PCI.
Stone GW, White HD, Ohman EM, et al.:Bivalirudin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a subgroup analysis from the Acute Catheterization and Urgent Intervention Triage strategy (ACUITY) trial.Lancet 2007,369:907–919.
Granger CB, Hirsch J, Califf RM, et al.:Activated partial thromboplastin time and outcome after thrombolytic therapy for acute myocardial infarction: results from the GUSTO-1 trial.Circulation 1996,93:870–878.
Rao SV, O’Grady K, Pieper KS, et al.:Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes.Am J Cardiol 2005,96:1200–1206.
Alexander KP, Chen AY, Roe MT, et al.:Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-elevation acute coronary syndromes.JAMA 2006,295:3108–3116.
Rao SV, Jollis JG, Harrington RA, et al.:Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.JAMA 2004,292:1555–1562.
Weitz JI, Bates SM:New anticoagulants.J Thromb Haemost 2005,3:1843–1853.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bates, E.R. New anticoagulant options for ST-elevation myocardial infarction and unstable angina pectoris/non-ST-elevation myocardial infarction. Curr Cardiol Rep 9, 289–297 (2007). https://doi.org/10.1007/BF02938377
Issue Date:
DOI: https://doi.org/10.1007/BF02938377