The role of low-molecular-weight heparin in the management of acute coronary syndromes
Marc Cohen, MD, FACC*,*
* Newark Beth Israel Medical Center, Division of Cardiology, Newark, New Jersey, USA
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Figure 1 The coagulation cascade. Interaction of the intrinsic pathway (initiated by the activation of Factor XI) and the extrinsic pathway (activated by vascular or tissue injury) results in a cascade of reactions that generate thrombin (Factor IIa). Thrombin is produced from prothrombin Factor II by the action of activated Factor X (Xa). Thrombin then acts on fibrinogen to generate fibrin, which undergoes crosslinking, resulting in a thrombin–fibrin clot.
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Figure 2 ESSENCE study: One-year follow-up trial results. Significant reductions were found in the composite end point of cardiovascular death, myocardial infarction (MI), and recurrent angina with enoxaparin treatment compared to treatment with unfractionated heparin (UFH). The need for diagnostic catheterization and coronary revascularization was also significantly reduced with enoxaparin treatment. ESSENCE, Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events. Reprinted with permission from the American College of Cardiology Foundation, J Am Coll Cardiol 2000;36:693–8.
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Figure 3 Meta-analysis of low-molecular-weight heparin (LMWH) trials in unstable angina/non–ST-segment elevation myocardial infarction: 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; LMWH = low-molecular-weight heparin; RRR = relative risk ratio; TIMI = Thrombolysis in Myocardial Infarction; UFH = unfractionated heparin. Adapted from Semin Thromb Hemost 1999;25 Suppl 3:113–21 (Fig. 3), with permission from Thieme Publishers, 2002.
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Figure 4 Event rates with enoxaparin with or without glycoprotein IIb/IIIa inhibitors in the NICE trials. MI = myocardial infarction; NICE = National Investigators Collaborating on Enoxaparin; TVUR = target vessel urgent revascularization. Kereiakes DJ, Grines C, Fry E. Enoxaparin and abciximab adjunctive pharmacotherapy during percutaneous coronary intervention. J Invas Cardiol 2001;13:272–8. Printed with permission from HMP Communications, 2002. Reprinted with permission from the American College of Cardiology Foundation, J Am Coll Cardiol 2001;37 Suppl A:1A–648A; Abstract 1253–97.
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Figure 5 Clinical event rates in ACUTE II trial. ACUTE = Antithrombotic Combination Using Tirofiban and Enoxaparin; enox = enoxaparin; MI = myocardial infarction; TIMI = Thrombolysis in Myocardial Infarction; tiro = tirofiban. Cohen M. Anti-thrombotic combination using tirofiban and enoxaparin: the ACUTE II study. Circulation 2000;102:II-826. Reproduced with permission from Lippincott, Williams and Wilkins.
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