COMPARISON OF ENOXAPARIN AND DALTEPARIN WITH UNFRACTIONATED HEPARIN IN THE TREATMENT OF NON-ST ELEVATED ACUTE CORONARY SYNDROME
Abstract
Background: The term non-ST elevated Acute Coronary Syndrome (ACS) encompasses unstableAngina (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
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.
Downloads
Published
How to Cite
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
