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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