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The role of low-molecular-weight heparin in the management of acute coronary syndromes

^* Newark Beth Israel Medical Center, Division of Cardiology, Newark, New Jersey, USA

Manuscript received May 31, 2002; revised manuscript received November 11, 2002, accepted November 19, 2002.

^* Reprint requests and correspondence: Dr. Marc Cohen, Division of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, New Jersey 07112, USA.
marc.cohen{at}sbhcs.com

A substantial number of clinical studies have consistently demonstrated that low-molecular-weight heparin (LMWH) compounds are effective and safe alternative anticoagulants to unfractionated heparins (UFHs). They have been found to improve clinical outcomes in acute coronary syndromes and to provide a more predictable therapeutic response, longer and more stable anticoagulation, and a lower incidence of UFH-induced thrombocytopenia. Of the several LMWH agents that have been studied in large clinical trials, including enoxaparin, dalteparin, and nadroparin, not all have shown better efficacy than UFH. Enoxaparin is the only LMWH compound to have demonstrated sustained clinical and economic benefits in comparison with UFH in the management of unstable angina/ non–ST-segment elevation myocardial infarction (NSTEMI). Also, LMWH appears to be a reliable and effective antithrombotic treatment as adjunctive therapy in patients undergoing percutaneous coronary intervention. Clinical trials with enoxaparin indicate that LMWH is effective and safe in this indication, with or without the addition of a glycoprotein IIb/IIIa inhibitor. The efficacy demonstrated by enoxaparin in improving clinical outcomes in unstable angina/NSTEMI patients has led to investigations of its role in the management of ST-segment elevation myocardial infarction. Initial results are very encouraging, and they indicate that enoxaparin may potentially substitute for UFH as adjunctive therapy in fibrin-specific thrombolytic regimens and improve coronary reperfusion rates in streptokinase-based regimens.

Abbreviations and Acronyms   ACS = acute coronary syndrome(s)   aPTT = activated partial thromboplastin time   GP = glycoprotein   LMWH = low-molecular-weight heparin   NSTEMI = non–ST-segment elevation myocardial infarction   PCI = percutaneous coronary intervention   tPA = tissue plasminogen activator   TVUR = target vessel urgent revascularization   UA = unstable angina   UFH = unfractionated heparin

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