Improved Reperfusion and Clinical Outcomes with Enoxaparin as an Adjunct to Streptokinase Thrombolysis in Acute Myocardial Infarction
Angeles Alonso
Clinical Puerta de Hierro, Madrid, Spain

Heparin is the recommended adjunct anticoagulant for administration with recombinant thrombolytic agents such as alteplase, but heparin should not be given with streptokinase. The results of this study demonstrate that enoxaparin is safe and effective for use as an anticoagulant in conjunction with streptokinase thrombolysis.

Dr. Alonso began by pointing out that heparin is recommended for anticoagulation in conjunction with reperfusion therapy using the thrombolytic agents alteplase, reteplase, or tenectaplase. However, heparin is not recommended for use with streptokinase. Because enoxaparin was shown in the HART II trial to provide early patency similar to that for unfractionated heparin and less reocclusion when used in conjunction with alteplase, this trial was designed to evaluate the use of enoxaparin with streptokinase. As Dr. Alonso noted, "Our hypothesis was that enoxaparin may provide improved early reperfusion, limitation of infarct size, and preservation of left ventricular function."

In this trial, 496 patients undergoing streptokinase reperfusion therapy for acute myocardial infarction were randomized to receive adjunctive anticoagulation with enoxaparin or placebo. All patients also received aspirin. The primary endpoint was improved TIMI 3 flow. The results showed that this was achieved in 70% of patients in the enoxaparin group compared with 58% of patients in the placebo group. The composite clinical endpoint of angina, myocardial infarction, or death at 30 days after the procedure was seen in 13% of the enoxaparin group versus 21% of the placebo group. Investigators found no significant differences between the two groups in terms of incidence of major bleeding, intracranial hemorrhage, or transfusion.

Dr. Alonso concluded: "Patients with acute myocardial infarction who received enoxaparin in conjunction with streptokinase and aspirin had better ST-segment resolution, indicating better reperfusion, better angiographic patency of the infarct-related vessel at 5 to 10 days after the procedure, and fewer adverse clinical events at 30 days, suggesting less reocclusion."

Reporter: Andre Weinberger, MD


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