Low molecular weight heparin (dalteparin) compared to unfractionated heparin as an adjunct to rt-PA (alteplase) for improvement of coronary artery patency in acute myocardial infarction—the ASSENT Plus study

Wallentin, Lars; Bergstrand, Lott; Dellborg, Mikael; Fellenius, C.; Granger, Christopher B.; Lindahl, Bertil; Lins, Lars‐Eric; Nilsson, Tage; Pehrsson, Kenneth; Siegbahn, Agneta; Swahn, Eva

doi:10.1016/s0195-668x(03)00006-x

Cited by 51 publications

(52 citation statements)

References 30 publications

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“…412 Other LMWH. There were 2 neutral meta-analyses of dalteparin, nadroparin, reviparin, parnaparin (LOE 5), 413,414 1 dalteparin supporting study using a surrogate end point (LOE 1), 415 and 3 neutral studies of LOE 1 416 for nandroparin 416 and parniparin. 417,418 Fondaparinux.…”

Section: Consensus On Sciencementioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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Section: Consensus On Sciencementioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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“…In 6 studies, follow-up was at least 99% complete, 6,15 -18,20 in the remaining study completeness of follow-up was not reported. 19 Clinical Outcome Figure 4) period, there were no statistically significant differences observed between the 2 groups.…”

Section: Quality Assessmentmentioning

confidence: 85%

“…In the Assessment of the Safety and Efficacy of Thrombolytic Regimens (ASSENT) Plus trial, initial intravenous bolus of dalteparin was 30 IU/kg. 19 After this, all subsequent injections of LMWHs were administered by subcutaneous route.…”

Section: Route Of Administration Of Lmwhsmentioning

confidence: 99%

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Adjunctive Low Molecular Weight Heparin During Fibrinolytic Therapy in Acute ST‐Segment Elevation Myocardial Infarction: A Meta‐Analysis Of Randomized Control Trials

Singh

Bahekar

Molnár

et al. 2009

Clinical Cardiology

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Background: Recent data suggests that low molecular weight heparins (LMWHs) may be superior to unfractionated heparin (UFH) as an adjunct to fibrinolytic therapy in patients with acute ST-segment elevation myocardial infarction (STEMI). Hypothesis: We evaluated cardiac outcomes and the risk of major bleeding with LMWHs vs UFH in the management of STEMI. Methods: Seven randomized trials of patients with acute STEMI treated with fibrinolytic therapy and adjunctive LMWHs through the index hospitalization or weight-based UFH for at least 48 hours were identified. We analyzed both primary endpoints (death and nonfatal recurrent myocardial infarction through 30 days), and secondary endpoints (death, recurrent myocardial infarction, and major bleeding during index hospitalization at 7 days). Outcomes were computed using the Mantel-Haenszel fixed-effect model. A 2-sided alpha error of <0.05 was considered significant. Results: Compared to UFH, LMWH significantly reduced reinfarction (p<0.001) during hospitalization at 7 days and the effect remained consistent at 30 d (p<0.001). When analyzed for mortality at 7 days and 30 days follow-up, there were no statistically significant differences observed between the 2 groups. Additionally the LMWH group had higher risk of major bleeding (p<0.001). Conclusions:The present meta-analysis suggests in patients receiving fibrinolytic therapy for STEMI, LMWHs as an adjunctive therapy is superior to UFH in reducing reinfarction during hospitalization at 7 days and at 30 days. The mortality was not significant between the 2 groups during hospitalization at 7 days and at 30 days. However, UFH is superior to LMWHs in the reduction of major bleeding at 7 days index hospitalization. IntroductionCurrent literature suggests the role of inflammation in the pathophysiology of coronary atherosclerosis.1 Nevertheless, formation of thrombus at the site of atherosclerotic plaque causing narrowing of coronary arteries remains the basis of acute coronary syndrome. 2 Fibrinolytic therapy given during acute myocardial infarction (AMI) can cause activation of coagulation cascade by release of thrombin bound to the clot. This may further lead to re-occlusion of coronary arteries. Use of intravenous heparin has been found to reduce the increased thrombin activity associated with thrombolysis. 3 Even though intravenous heparin does

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“…[32][33][34][35] In the ASSENT-3 trial, full-dose TNK-tPA plus enoxaparin (given as an intravenous bolus of 30 mg followed by 1 mg/kg subcutaneously over a period of 12 hours) significantly reduced ischemic complications of STEMI, including reinfarction, without affecting intracranial hemorrhage rates or mortality rates. 30 There was, however, a moderate increase in noncerebral bleeding complications.…”

Section: Optimal Dose Of Heparin and Uncertainties About New Antithromentioning

confidence: 99%

Pharmacoinvasive Therapy

Antman

Werf²

2004

Circulation

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Low molecular weight heparin (dalteparin) compared to unfractionated heparin as an adjunct to rt-PA (alteplase) for improvement of coronary artery patency in acute myocardial infarction—the ASSENT Plus study

Abstract: In alteplase treated AMI adjunctive dalteparin for 4-7 days seems to reduce the risk of early coronary artery occlusion and reinfarction. However, early after cessation of treatment there is a raised risk of events, which might eliminate any long-term gains.

Cited by 51 publications

References 30 publications

Part 9: Acute Coronary Syndromes

Part 9: Acute Coronary Syndromes

Adjunctive Low Molecular Weight Heparin During Fibrinolytic Therapy in Acute ST‐Segment Elevation Myocardial Infarction: A Meta‐Analysis Of Randomized Control Trials

Pharmacoinvasive Therapy

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