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      Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis

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          Abstract

          Objective To determine the efficacy and safety of enoxaparin compared with unfractionated heparin during percutaneous coronary intervention.

          Design Systematic review and meta-analysis.

          Data sources Medline and Cochrane database of systematic reviews, January 1996 to May 2011.

          Study selection Randomised and non-randomised studies comparing enoxaparin with unfractionated heparin during percutaneous coronary intervention and reporting on both mortality (efficacy end point) and major bleeding (safety end point) outcomes.

          Data extraction Sample size, characteristics, and outcomes, extracted independently and analysed.

          Data synthesis 23 trials representing 30 966 patients were identified, including 10 243 patients (33.1%) undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction, 8750 (28.2%) undergoing secondary percutaneous coronary intervention after fibrinolysis, and 11 973 (38.7%) with non-ST elevation acute coronary syndrome or stable patients scheduled for percutaneous coronary intervention. A total of 13 943 patients (45.0%) received enoxaparin and 17 023 (55.0%) unfractionated heparin. Enoxaparin was associated with significant reductions in death (relative risk 0.66, 95% confidence interval 0.57 to 0.76; P<0.001), the composite of death or myocardial infarction (0.68, 0.57 to 0.81; P<0.001), and complications of myocardial infarction (0.75, 0.6 to 0.85; P<0.001), and a reduction in incidence of major bleeding (0.80, 0.68 to 0.95; P=0.009). In patients who underwent primary percutaneous coronary intervention, the reduction in death (0.52, 0.42 to 0.64; P<0.001) was particularly significant and associated with a reduction in major bleeding (0.72, 0.56 to 0.93; P=0.01).

          Conclusion Enoxaparin seems to be superior to unfractionated heparin in reducing mortality and bleeding outcomes during percutaneous coronary intervention and particularly in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction.

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          Most cited references83

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          Guidelines on myocardial revascularization.

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            Bivalirudin during primary PCI in acute myocardial infarction.

            Treatment with the direct thrombin inhibitor bivalirudin, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in similar suppression of ischemia while reducing hemorrhagic complications in patients with stable angina and non-ST-segment elevation acute coronary syndromes who are undergoing percutaneous coronary intervention (PCI). The safety and efficacy of bivalirudin in high-risk patients are unknown. We randomly assigned 3602 patients with ST-segment elevation myocardial infarction who presented within 12 hours after the onset of symptoms and who were undergoing primary PCI to treatment with heparin plus a glycoprotein IIb/IIIa inhibitor or to treatment with bivalirudin alone. The two primary end points of the study were major bleeding and combined adverse clinical events, defined as the combination of major bleeding or major adverse cardiovascular events, including death, reinfarction, target-vessel revascularization for ischemia, and stroke (hereinafter referred to as net adverse clinical events) within 30 days. Anticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in a reduced 30-day rate of net adverse clinical events (9.2% vs. 12.1%; relative risk, 0.76; 95% confidence interval [CI] 0.63 to 0.92; P=0.005), owing to a lower rate of major bleeding (4.9% vs. 8.3%; relative risk, 0.60; 95% CI, 0.46 to 0.77; P<0.001). There was an increased risk of acute stent thrombosis within 24 hours in the bivalirudin group, but no significant increase was present by 30 days. Treatment with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in significantly lower 30-day rates of death from cardiac causes (1.8% vs. 2.9%; relative risk, 0.62; 95% CI, 0.40 to 0.95; P=0.03) and death from all causes (2.1% vs. 3.1%; relative risk, 0.66; 95% CI, 0.44 to 1.00; P=0.047). In patients with ST-segment elevation myocardial infarction who are undergoing primary PCI, anticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in significantly reduced 30-day rates of major bleeding and net adverse clinical events. (ClinicalTrials.gov number, NCT00433966 [ClinicalTrials.gov].). Copyright 2008 Massachusetts Medical Society.
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              ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention).

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                Author and article information

                Contributors
                Role: associate professor
                Role: professor
                Role: senior consultant
                Role: professor
                Role: professor
                Role: professor
                Role: professor
                Role: professor
                Role: associate professor
                Role: professor
                Role: professor
                Role: professor
                Journal
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1468-5833
                2012
                2012
                03 February 2012
                : 344
                : e553
                Affiliations
                [1 ]Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Boulevard de l’Hopital, 75013 Paris, France
                [2 ]Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA, USA
                [3 ]Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ, USA
                [4 ]Herzzentrum Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
                [5 ]Department of Internal Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, Austria
                [6 ]SAMU, CHRU Lille, France
                [7 ]Cardiology Department, Centre Hospitalier Carémeau, Nîmes, France
                [8 ]Unité de Recherche Clinique, Lariboisière Hospital, Paris, France
                Author notes
                Correspondence to: G Montalescot gilles.montalescot@ 123456psl.aphp.fr
                Article
                silj003078
                10.1136/bmj.e553
                3271999
                22306479
                6ede9d49-ebbf-468e-9165-b5c747b0b98c
                © Silvain et al 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 19 January 2012
                Categories
                Research
                Epidemiologic Studies
                Drugs: Cardiovascular System
                Stroke
                Interventional Cardiology
                Ischaemic Heart Disease
                Cardiothoracic Surgery
                Vascular Surgery
                Internet

                Medicine
                Medicine

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