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REVIEW ARTICLE

Low molecular weight heparin in acute coronary syndrome: evidence for superior or equivalent efficacy compared with unfractionated heparin?

Sanjay Kaul, MD^{* c} and Prediman K. Shah, MD, FACC^{* c}

^* Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
^c UCLA School of Medicine, Los Angeles, California, USA

Manuscript received March 10, 1999; revised manuscript received December 16, 1999, accepted February 21, 2000.

Reprint requests and correspondence: Dr. Sanjay Kaul, Division of Cardiology, 5314 North Professional Tower, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048
kaul{at}cshs.org

This article will review the results of recent clinical trials evaluating low molecular weight heparins (LMWHs) in the management of patients with acute coronary syndromes of unstable angina and non-ST segment elevation MI. Low molecular weight heparins are a new class of anticoagulants that have a number of advantages over unfractionated heparin (UFH) leading to their increasing use for thrombotic vascular disorders. There is convincing evidence that LMWH is more effective than placebo and at least as effective as UFH in reducing the hard end points of death and recurrent myocardial infarction. Convincing evidence for a superior efficacy is mostly limited to the least robust but most prevalent end point of recurrent angina, and benefits appear to be confined predominantly to high-risk patients. The benefits are sustained long-term, but there appears to be no incremental benefit with prolonged treatment. The risk for major bleeding is approximately equivalent to UFH, but minor hemorrhage is clearly increased, especially with vascular instrumentation. The increased bleeding risk together with its long half-life and absence of specific antidote warrants exercising caution when using LMWH with coronary intervention. Low molecular weight heparins have the potential of being cost-neutral or even cost-saving by reducing resource utilization, especially in the setting of aggressive interventional practice pattern. Last, the issue of whether one LMWH preparation is more effective and cost-effective than others remains an open question that can be answered only by direct head-to-head comparison of different LMWH preparations in randomized trials. In conclusion, subcutaneous weight-adjusted LMWH is as effective and safe as intravenous UFH in the management of patients with acute coronary syndromes. The logistic ease of administration without the need for monitoring anticoagulation appears to be the major advantage over UFH.

Abbreviations and Acronyms   ACLM = above critical length molecules   ACS = acute coronary syndrome   AUC = area under the curve   BCLM = below critical length molecules   CABG = coronary artery bypass grafting   ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q Wave Coronary Events   FRAXIS = Fraxiparine in Ischemic Syndromes   FRIC = Fragmin in Unstable Coronary artery disease   FRISC = Fragmin during InStability in Coronary artery disease   FRISC II = Fragmin and Fast Revascularization during InStability in Coronary artery disease   LMWH = low molecular weight heparin   MI = myocardial infarction   NQMI = non-Q-wave myocardial infarction   PF4 = platelet factor 4   PTCA = percutaneous transluminal coronary angioplasty   TFPI = tissue factor pathway inhibitor   TIMI-11B = Thrombolysis in Myocardial Infarction 11B   UA = unstable angina   UFH = unfractionated heparin   vWF = von Willebrand factor

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