COMPARISON OF ENOXAPARIN AND DALTEPARIN WITH UNFRACTIONATED HEPARIN IN THE TREATMENT OF NON-ST ELEVATED ACUTE CORONARY SYNDROME

Mushtaq Ahmed, Mohammad Tariq, Lubna Noor, Shahab Ud Din, Mohammad Hafizullah

Abstract


Background: The term non-ST elevated Acute Coronary Syndrome (ACS) encompasses unstable
Angina (USA) and non-ST segment elevated Myocardial Infarction (NSTEMI), both of which
may end up in death or a fatal/non-fatal Myocardial Infarction (MI). Unfractionated heparin
(UFH) has been shown to reduce death and MI in patients with USA and NSTEMI. Of late, there
has been a great interest in the role of low molecular weight heparins (LMWHs) in the two
conditions and they have been found to be at least as effective as or even more effective than
UFH. Methods: A total of 90 patients who presented to CCU of Khyber Teaching Hospital,
Peshawar with USA or NSTEMI, from June 2008 to June 2009, were enrolled into the study. An
equal number of patients were randomly assigned to one of the three arms for 5 days each: Group
A received enoxaparin, group B received dalteparin and group C received UFH. The primary end
points of the study were all cause mortality, STEMI, refractory USA, recurrent USA or a major
bleed. The secondary end point was minor bleeding. Results: At the end of the study, there were 2
deaths each in the dalteparin and UFH group, whereas no such event was recorded in the
enoxaparin group. Two patients had STEMI in the UFH group but none in the other two groups.
Conclusion: LMWHs are far more superior to unfractionated heparin.
Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Atherosclerosis, Unstable Angina,
Myocardial Infarction, Unfractionated Heparin, low-molecular weight heparin

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References


Hirsh J, Fuster V. Guide to anticoagulant therapy. Part 1:

Heparin. Circulation 1994;89:1449–68.

Lane DA, Pejler G., Flynn AM, Thompson EA, Lindahl U.

Neutralization of heparin-related saccharides by histidine-rich

glycoprotein and platelet factor 4. J Biol Chem

;261:3980–6.

Barradas MA, Mikhailidis DP, , Epemolu O, Jeremy JY,

Fonseca V, Dandona P. Comparison of the platelet proaggregatory effect of conventional unfractionated heparin and

a low molecular weight heparin fraction (CY 222). Br J

Haematol 1987;67:451–7.

Hirsh J, Warkentin TE, Raschke R, Granger C, Ohman EM,

Dalen JE. Heparin and low molecular weight heparin:

mechanism of action, pharmacokinetics, dosing

considerations, monitoring, efficacy, and safety. Chest

;114(suppl):489–510S.

Holt JC, Niewiarowski S. Biochemistry of alpha-granule

proteins. Semin Hematol 1985;22:151–63.

Friedman Y, Arsenis C. Studies on the heparin sulphamidase

activity from rat spleen: intracellular distribution and

characterization of the enzyme. Biochem J 1974;139:699–708.

Weitz JI, Hudoba M, Massel D, Maraganore J, Hirsh J. Clobound thrombin is protected from inhibition by heparinantithrombin III but is susceptible to inactivation by

J Ayub Med Coll Abbottabad 2011;23(3)

http://www.ayubmed.edu.pk/JAMC/23-3/Mushtaq.pdf 63

antithrombin III-independent inhibitors. J Clin Invest

;86:385–91.

Bar-Shavit R, Eldor A, Vlodavsky I. Binding of thrombin to

subendothelial extracellular matrix: protection and expression

of functional properties. J Clin Invest 1989;84:1096–104.

Theroux P, Waters D, Lam J. Reactivation of unstable angina

after the discontinuation of heparin. N Engl J Med

;327:141–5S.

Young E, Prins MH, Levine MN. Heparin binding to plasma

proteins, an important mechanism for heparin resistance.

Thromb Haemost 1992;67:639–43.

Levine M, Hirsh J. Hemorrhagic complications of

anticoagulant therapy. Semin Thromb Hemost 1986;12:39–57.

Ginsberg JS, Kowalchuk G, Hirsh J. Heparin effect on bone

density. Thromb Haemost 1990;64:286–9.

Warkentin TE, Kelton JG. Heparin-induced

thrombocytopenia. Annu Rev Med 1989;40:31–44.

Ofosu FA, Barroweliffe TW. Mechanisms of action of low

molecular weight heparins and heparinoids. In: Hirsh J, ed.

Antithrombotic therapy, Bailliere’s clinical haematology, (vol-

. London: Bailliere Tindall; 1990;505–29.

Handeland GF, Abidgaard GF, Holm U. Dose adjusted

heparin treatment of deep venous thrombosis: a comparison of

unfractionated and low molecular weight heparin. Eur J Clin

Pharmacol 1990;39:107–12.

Nightingale SL From the food and drug Administration.

Appropriate use of low molecular weight heparins. JAMA

;270(4):1672.

Neri Serneri GGN, Gensini GF, Poggesi L. Effect of heparin,

aspirin, or alteplase in reduction of myocardial ischaemia in

refractory unstable angina. Lancet 1990;335:615–8.

Antman EM. The search for replacements for unfractionated

heparin. Circulation 2001;103:2310–14.

Wong GC, Giugliano RP, Antman EM. Use of LowMolecular-Weight Heparins in the Management of Acute

Coronary Artery Syndromes and Percutaneous Coronary

Intervention. JAMA 2003;289:331–42.

Montalescot G, Bal-dit-Sollie C, Chibedi D, Collet JP, Soulat

T, Dalby M, et al. Comparison of effects on markers of blood

cell activation ofenoxaparin, dalteparin, and unfractionated

heparin in patients with unstable angina pectoris or non–STsegment elevation acute myocardial infarction (the ARMADA

study). Am J Cardiol 2003;91:925–30.

Petersen JL, Mahaffey KW, Hasselblad V, Antman EM,

Cohen M, Goodman SG, et al. Efficacy and bleeding

complications among patients randomized to enoxaparin or

unfractionated heparin for antithrombin therapy in non-STSegment elevation acute coronary syndromes: A systematic

overview. JAMA 2004;292:89–96.

Baird SH, Menown IB, McBride SJ, Trouton TG, Wilson C.

Randomized comparison of enoxaparin with unfractionated

heparin following fibrinolytic therapy for acute myocardial

infarction. Eur Heart J 2002;23:627–32.

Klein W, Buchwald A, Hillis SE, Monrad S, Sanz G, Turpie

AGG, Meer JVD, et al. Comparison of low molecular weight

heparin with unfractionated heparin acutely and with placebo

for 6 weeks in the management of unstable coronary artery

disease. Fragmin in Unstable Coronary Artery Disease Study

(FRIC). Circulation 1997;96(1):61–8.

Cohen M, Demers C, Gurfinkel EP, Turpie AGG, Fromell GJ,

Goodman S, et al. A comparison of low molecular weight

heparin with unfractionated heparin for unstable coronary

artery disease. Efficacy and Safety of Subcutaneous

Enoxaparin in Non-Q-Wave Coronary Events Study Group. N

Engl J Med 1997;337:447–52.

Goodman SG, Cohen M, Bigonzi F, Gurfinkel EP, Radley

DR, Le Iouer V, et al. Randomized trial of low molecular

weight heparin (enoxaparin) versus unfractionated heparin for

unstable coronary artery disease: one year results of the

ESSENCE study. Efficacy and Safety of Subcutaneous

Enoxaparin in Non-Q-Wave Coronary Events. J Am Coll

Cardiol 2000;36:693–8.

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf

RM, Casey DE, et al. ACC/AHA 2007 Guidelines for the

Management of Patients With Unstable Angina/Non–STElevation Myocardial Infarction: A Report of the American

College of Cardiology/American Heart Association Task

Force on Practice Guidelines (Writing Committee to Revise

the 2002 Guidelines for the Management of Patients With

Unstable Angina/Non–ST-Elevation Myocardial Infarction)

Developed in Collaboration with the American College of

Emergency Physicians, the Society for Cardiovascular

Angiography and Interventions, and the Society of Thoracic

Surgeons Endorsed by the American Association of

Cardiovascular and Pulmonary Rehabilitation and the Society

for Academic Emergency Medicine. JACC 2007;50:e1–157.


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