CLINICAL STUDY
Low molecular weight heparin decreases rebound ischemia in unstable angina or non-Q-wave myocardial infarction: the Canadian ESSENCE ST segment monitoring substudy
Shaun G. Goodman, MD, FACC*,
Aiala Barr, PhD*,
Anatoli Sobtchouk, MD*,
Marc Cohen, MD, FACC ,
Gregg J. Fromell, MD ,
Luc Laperrière, MD ,
Carol Hill, RN*,
Anatoly Langer, MD, FACC* for the Canadian Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) ST Segment Monitoring Substudy Group
* Canadian Heart Research Center, Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Canada
Division of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania, USA
Covance Clinical Trials Research and Development, Inc., Princeton, New Jersey, USA
Fournier Pharma and Department of General Medicine, Hospital Center of the University of Montreal, Montreal, Quebec, Canada
Manuscript received October 21, 1999;
revised manuscript received April 24, 2000,
accepted June 19, 2000.
Reprint requests and correspondence: Dr. Shaun G. Goodman, St. Michael’s Hospital, Division of Cardiology, 30 Bond Street, Room 9-005 Queen, Toronto, Ontario, Canada M5B 1W8
goodmans{at}smh.toronto.on.ca
OBJECTIVES
The goal of this study was to determine whether enoxaparin was more effective than heparin in reducing recurrent ischemic episodes.
BACKGROUND
Continuous ST segment monitoring is a simple tool for assessment of ischemia and identifies patients with a worse prognosis. Little is known about the impact of low molecular weight heparin on ST segment shift.
METHODS
Patients were randomized to receive enoxaparin or heparin (mean 3.4 days). Three-lead ST segment monitoring was performed for the first 48 h (n = 220) and an additional 48 h (n = 174) after intravenous study drug discontinuation (mean 1.9 days later).
RESULTS
During initial monitoring, ischemia rates were similar among the heparin and enoxaparin groups (27.2% vs. 22.6%, p = 0.44); however, the time to first ischemic episode was earlier among heparin-treated patients (11 ± 11 vs. 25 ± 18 min, p = 0.001). After drug discontinuation, ischemic episodes occurred more frequently (44.6% vs. 25.6%, p = 0.009), and the total ischemic duration was greater among heparin patients (18 ± 39 vs. 5 ± 12 min/24 h, p = 0.005). Recurrent ischemia occurred more frequently after discontinuation in the heparin (46% vs. 31%, p = 0.043), but not the enoxaparin, group (18.4% vs. 25%, p = 0.33). Regardless of treatment, patients with ischemia were more likely to die or experience (re)infarction at one year (18.4% vs. 8.3%, p = 0.023).
CONCLUSIONS
ST segment shift occurs frequently in unstable angina/non-Q-wave myocardial infarction despite antithrombotic therapy and is associated with worse one-year prognosis. Enoxaparin is a more effective antithrombotic treatment than unfractionated heparin and leads to greater prevention of rebound ischemia.
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Abbreviations and Acronyms
| | CI | = confidence interval | | ECG | = electrocardiograph | | ESSENCE | = Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events | | LMWH | = low molecular weight heparin | | MI | = myocardial infarction | | OR | = odds ratio | | UFH | = unfractionated heparin |
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